Fractions of an antimalarial neem-leaf extract have activities superior to chloroquine, and are gametocytocidal

The antimalarial activities of two fractions (IRDN-A and IRDN-B) of an extract from the leaves of the neem tree (Azadirachta indica) were compared with those of chloroquine, in in-vitro assays against Plasmodium falciparum. The asexual stages of a chloroquine-sensitive clone (ITG2F6) and a chloroquine-resistant isolate (W2) and the gametocytes of the NF 54 (BD-7) isolate of P. falciparum were used as the drug targets. Activity against the asexual stages was generally evaluated as the concentrations inhibiting the parasitaemias recorded in the control cultures, after an incubation of 48-72 h, by 50% (IC50) or 100% (IC100). For the ITG2F6 strain, the IC50 and IC100 (in microg/ml) were, respectively, 10(-5) and 10(-4) for IRDN-A, 10(-3) and 10(-2) for IRDN-B, and 10(-2) and 1.0 for chloroquine. The corresponding values for the W2 strain were 10(-5) and 1.0 for IRDN-A, and 10.0 and >100 for chloroquine (even at 100 microg/ml, chloroquine only inhibited the parasitaemia by 85%). Each of the two neem-leaf fractions lysed 50% and 100% of developing gametocytes, at 10(-3) and 1.0 microg/ml, respectively; and 50% and 100% of mature gametocytes at 10(-3) and 10(2) microg/ml, respectively. If they are found safe and effective in vivo, the neem-leaf fractions may form the basis of new antimalarial drugs that not only cure chloroquine-sensitive and chloroquine-resistant malaria but also markedly reduce transmission.

Low-dose lisinopril in normotensive men with idiopathic oligospermia and infertility: a 5-year randomized, controlled, crossover pilot study

The outcomes of drug treatment for male infertility remain conjectural, with controversial study results. Our pilot study employed a randomized, placebo-controlled, crossover methodology with intention-to-treat analysis. Thirty-three men with idiopathic oligospermia were randomized to start either daily oral lisinopril 2.5 mg (n = 17) or daily oral placebo (n = 16). Lisinopril was found to cause a normalization of seminal parameters in 53.6% of the participants. Although the mean ejaculate volume was unchanged (P ≥ 0.093), the total sperm cell count and the percentage of motile sperm cells increased (P ≤ 0.03 and P < 0.001, respectively), whereas the percentage of sperm cells with abnormal morphology decreased (P ≤ 0.04). The pregnancy rate was 48.5%, and there was no serious adverse drug event. It is concluded, albeit cautiously, that prolonged treatment with 2.5 mg/day of oral lisinopril may be well tolerated in normotensive men with idiopathic oligospermia, may improve sperm quantity and quality, and may enhance fertility in approximately half of those treated.

Fractionated neem leaf extract is safe and increases CD4+ cell levels in HIV/AIDS patients

The safety and effect of an acetone-water neem leaf extract (IRAB) on CD4 cells was investigated in 60 HIV/AIDS patients as part of an ongoing study to determine the influence of neem on immunity and viral load in HIV/AIDS. Patients were confirmed as HIV I or II positive, as having CD4 cell count, less than 300 cells/microL, and as antiretrovirally naïve. They were given oral IRAB (1.0 g daily for 12 weeks). Clinical and laboratory tests were carried out at baseline and at 4 weekly intervals. Thus, the patients served as their own controls. Sixty patients completed treatment. Fifty (83.33%) were completely compliant with respect to laboratory tests. Increase in mean CD4 cells, 266 cells/microL (159%), for the 50 patients was significant (P < 0.001) between baseline and week 12. Erythrocyte sedimentation rate (64 mm/hr at baseline) was 16 mm/hr at week 12, whereas total number of incidences of HIV/AIDS-related pathologies decreased from 120 at baseline to 5. Mean bodyweight, hemoglobin concentration, and lymphocyte differential count increased significantly by 12% (P < 0.05), 24% (P < 0.0001), and 20% (P < 0.0001), respectively. There were no adverse effects and no abnormalities in kidney and liver function parameters. The results support the safety of IRAB in HIV/AIDS, and its significant influence on CD4 cells may be useful in the formulation of multidrug combination therapies for HIV/AIDS. However, its antiretroviral activity is being evaluated in our laboratory.

Willingness to pay for treatment with highly active antiretroviral (HAART) drugs: a rural case study in Cameroon

This paper reports on the willingness of HIV/AIDS patients to pay for the most affordable triple therapy combination of antiretrovirals in a local setting in Cameroon. Questionnaires were used to evaluate willingness to pay, and patients who could still afford their medication 6 months after the survey were also investigated, to give an indication of actual ability to pay. In addition, oral interviews were carried out for clarification. In all, 84 patients out of a total of 186 were involved in the study. Results indicated that more men (39%) were willing to pay than women (22%), although more women (56%) were afflicted than men. Willingness to pay was directly dependent on cost with 69%, 22% and 9% of respondents indicating willingness to pay $1, $2 and $3 a day respectively. After 6 months of treatment, 22% of patients were still on therapy. A majority of patients stopped taking the drugs after 6 months due to financial constraints. Apart from cost, stigma, disbelief and side-effects of medication were found to be the main factors militating against willingness to pay. Improved counselling and provision of information, reduced cost of drugs including laboratory tests, and destigmatisation programmes are recommended to improve patients' ability to pay for antiretrovirals.

The pattern of home treatment of malaria in under-fives in south eastern Nigeria

Malaria remains a major public health problem in most countries of the tropics with high morbidity and mortality. The toll of the disease is highest on the under-fives. The actions mothers take in the management of children with malaria is important in the fight to check the malaria scourge. A cross sectional survey was carried out in two states in southeast Nigeria--Abia and Anambra states. A multi-stage sampling technique was used to select the subjects. One thousand two hundred and sixty mothers with children under five years of age were selected from 6 Local Government Areas in the two states. Trained interviewers were used to conduct the survey. The mean age of the mothers was 30.51 +/- 6.76. Over 95% (1016) of the respondents had at least a primary school education. The first line of actions mothers took when their under-five children had malaria showed that 54.5% (687) of them either procured medicines from the patent medicine dealers or used medicines that were in the home. The two most commonly used drugs for malaria treatment for under-fives were chloroquine 65.4% (824) and pyrimethamine/sulfadoxine 12.3% (155). Between 11.5% and 46% of the mothers used correct doses of chloroquine syrup while 5.3% and 11.5% of them used correct doses of chloroquine tablets. The proportion of mothers that used correct doses of pyrimethamine/sulfadoxine tablets was comparatively higher (36.4% and 75%) than the others. Large proportion of mothers (61%) who manage malaria at home, do so inappropriately. Proper health education needs to be set up to enlighten the populace on mode of home treatment for malaria in order to reduce the disease burden on families.

An antimalarial extract from neem leaves is antiretroviral

An acetone-water neem leaf extract with antimalarial activity was evaluated in vitro at 5 microg/ml for inhibition of adhesion of malaria parasite-infected erythrocytes and cancer cells to endothelial cells, and at 10 microg/ml for protection of lymphocytes against invasion by HIV. The extract was also evaluated in 10 patients with HIV/AIDS at 1000 mg daily for 30 d. The mean binding of infected erythrocytes and cancer cells per endothelial cell was 15 and 11 respectively in the absence of the extract, and 0 and 2 respectively in with the extract. In the absence and presence of the extract, 0% and 75%, respectively, of lymphocytes were protected. In the treated patients, haemoglobin concentration, mean CD4+ cell count and erythrocyte sedimentation rate, which were initially 9.8 g/dl, 126 cells/microl and 90 mm/h respectively, improved to 12.1 g/dl, 241 cells/microl and 49 mm/h. Mean bodyweight and platelet count, initially 57 kg and 328 x 10(3)/mm3 respectively, increased to 60 kg and 359 x 10(3)/mm3. No adverse effects were observed during the study. The extract showed antiretroviral activity with a mechanism of action that may involve inhibition of cytoadhesion. The results may help in the development of novel antiretroviral and antimalarial drugs.

Community-based ivermectin therapy for onchocerciasis: comparison of three methods of dose assessment

A new method of assessment based on mid-upper arm circumference (MUAC) is described for dosage adjustment for community-based ivermectin distribution. We studied 878 subjects eligible for ivermectin dosing in Awhum, Nigeria. In a previous preliminary study of 40 persons, MUAC (in cm) correlated with weight (kg) in the first 20 male (r = 0.97, r2 = 0.95, P < 0.0001) and the first 20 female subjects (r = 0.94, r2 = 0.88, P < 0.0001). We therefore studied the use of height, physical appearance, and MUAC for calculating the dose of ivermectin. The MUAC-based schedule underdosed only 4.1% of the population. The methods based on height underdosed 3.3% and 21.1%, and assignment based on physical appearance underdosed 10.2% of the population studied. This MUAC-based method (13-15 cm, 0.5 tablet; 16-20 cm, 1.0 tablet; 21-27 cm, 1.5 tablets; > or = 28 cm, 2.0 tablets) is more convenient and corresponds closely to dosing by weight. An adaptation of this method with reference to other prevalent tropical diseases and their respective drugs is therefore advocated.

How do rural households perceive and prioritise malaria and mosquito nets? A study in five communities of Nigeria

The aim of this study was to determine households' levels of prioritization and perception of malaria, ordinary mosquito nets and insecticide-treated nets (ITNs). A cross-sectional survey was conducted in five malaria holo-endemic communities in Enugu State, South-eastern Nigeria. The household heads or the representatives from randomly selected households were interviewed, using a pre-tested interviewer-administered questionnaire. The majority of the respondents had a good knowledge about malaria and the use of ordinary mosquito nets to prevent malaria. However, few knew about the existence of ITNs. Most respondents also stated that malaria was a priority problem and perceived some risk of contracting it. Despite the high level of knowledge about the use of mosquito nets, only 14.0%, 15.7%, 9.6% and 8.0% of the respondents from four of the communities had ever purchased any type of mosquito nets, except in Orba where the proportion was 50.3%. However, more than 80% in all the communities expressed a desire to buy insecticide-treated mosquito nets for the prevention of mosquito bites. There was considerable knowledge about malaria and the use of mosquito nets to prevent it. There were also high levels of prioritization of the disease, mosquito nets and ITNs which signalled the possibility of establishing sustainable community-based ITN programmes, especially as households wanted to buy the ITNs.

Community financing of local ivermectin distribution in Nigeria: potential payment and cost-recovery outlook

The preferred payment mechanism in a community financing scheme for local ivermectin distribution was elicited from randomly selected household heads from three communities in Nigeria using interviewer-administered structured questionnaires. The majority of the respondents in the three communities were prepared to pay for local ivermectin distribution. Additionally, the average amounts the respondents were prepared to pay per person treated ($0.28, $0.30 and $0.38 in Nike, Achi and Toro, respectively) were all more than the $0.20 ceiling recommended by the partners of the African Programme on Onchocerciasis Control (APOC). Thus, the cost-recovery outlook is bright in these communities. However, the preferred payment modality varied. Fee-for-service was the predominant payment modality in the Achi and Nike communities, while the Toro community preferred pre-payment. This study demonstrates that many communities have different payment preferences for endemic disease control efforts. This knowledge will help in developing acceptable and sustainable schemes. The imposition of unacceptable payment mechanisms will lead to an unwillingness to pay.

A health club for a community school in south-eastern Nigeria: influence on adult perception of onchocerciasis and compliance with community-based ivermectin therapy

The impact of a school health club on adult perception of onchocerciasis and compliance with ivermectin was evaluated in an onchocerciasis-endemic community in southeastern Nigeria. Venous blood was collected from each of 26, 32 and 124 randomly selected subjects during ivermectin distribution programmes in 1995 1996 and 1997 respectively. Ivermectin concentrations were measured in the samples. Data was also collected from 334 and 319 randomly selected household heads or their representatives (aged 24 to 65 years) before and after health talks by schoolchildren, using interviewer-administered questionnaires. There was an increasing number of subjects who participated in control programmes (116 in 1995, 437 in 1996 and 2055 in 1997). Compliance with ivermectin treatment was low (53.9%) in 1995 but increased dramatically (90.1%) in 1997. A significant proportion (chi2 = 108.7, df = 1, P < 0.0001) of respondents knew about onchocerciasis after health education, predominantly from health workers (64.5%) before the tests and children (92.3%) after. Knowledge and beliefs about causative agents (chi2 = 266.4, df = 5, P < 0.0001), diagnostic method (chi2 = 207.4, df = 3, P < 0.0001), prevention (chi2 = 67.0, df = 4, P < 0.0001) of onchocerciasis and the effectiveness of ivermectin (chi2 = 40.4, df = 1, P < 0.0001) also differed significantly between the periods before and after tests. The school health club increased adult knowledge about onchocerciasis and its treatment. Schoolchildren could therefore supplement the information, education and communication (IEC) aspect of health care delivery in a community through such health clubs.

Ivermectin: concentration-dependent effects on adenosine triphosphatases in adult worms of Onchocerca volvulus

The effect of increasing concentrations of ivermectin on adenosine triphosphatase (ATPase) activity was investigated in adult worms of Onchocerca volvulus. Mean Mg- and Na,K-ATPase activities decreased significantly (F ratio = 29.82, P < 0.01 and F ratio = 28.54, P < 0.01, respectively) with increasing concentrations of ivermectin (0-100 ng/ml) in the female worms. When male and female worms were mixed with equal amounts of proteins from each, only the Na,K-ATPase activity was significantly decreased (F ratio = 56.61, P < 0.01) over a similar range of ivermectin concentrations. Since ivermectin exhibits concentration-dependent effects on both ATPases in female adult worms, this might provide an insight into other effects of the drug. However, the adjustment of the dose of ivermectin to obtain a nodular concentration of at least 40 ng/ml is therefore recommended in the complete chemotherapy of onchocerciasis.

Health education to school children in Okpatu, Nigeria: impact on onchocerciasis-related knowledge

We assessed the influence of health education on the knowledge about onchocerciasis in school children in Okpatu, Nigeria. The children, aged between 11 and 17 y, received health education in both English and Igbo (local language) for three months on the transmission, clinical manifestations, treatment and prevention of onchocerciasis. Illustrated pictorial materials were used to support and enhance their understanding of the subject matter. Their level of knowledge was evaluated nine months later using a pre-tested personal interview administered questionnaire. A significantly higher proportion of these children knew about onchocerciasis (chi2=260.4, df=1, P<0.0001), and its causative agent (chi2=175.0, df=4, P<0. 0001), clinical manifestations (chi2=254.0, df=5, P<0.0001), diagnosis (chi2=123.9, df=2, P<0.0001), treatment (chi2=197.8, df=3, P<0.0001) and prevention (chi2=220.8, df=3, P<0.0001) in the post- than in the pre-educational intervention. It is therefore concluded that school-based health education showed an increase in knowledge about onchocerciasis and school children could provide a useful 'multiplier' resource for health education in the community.

Willingness to pay for the maintenance of equity in a local ivermectin distribution scheme in Toro, Northern Nigeria

The willingness to pay (WTP) for the maintenance of equity in a local ivermectin distribution scheme in the context of a community financing framework was determined in Toro, Northern Nigeria, using 214 randomly selected heads of households, or their representatives. Though WTP of the respondents for their own households was elicited, the focus of this paper is on WTP to maintain equity in a community financing scheme. Contingent valuation was used for the exercise, and WTP was elicited using an open-ended question. 97.2% of the respondents were in favour of allowing those that lack the ability to pay, to benefit from the scheme and the maximum WTP amounts they were willing to contribute annually so that those who lack the ability to pay could benefit from the scheme ranged from 5 Naira ($0. 06) to 100 Naira ($1.25). The mean WTP to maintain equity was 29.00 Naira ($0.36) while the median was 20.00 Naira ($0.25). This study shows that a community financing scheme for local ivermectin distribution will not be inequitable, since enough funds will be realised from well-to-do community members to cover the costs for those who are unable to pay.

Influence of health education on community participation in rapid assessment of onchocerciasis prior to distribution of ivermectin

OBJECTIVE

To investigate the impact of health education on community participation in the rapid assessment of onchocerciasis prior to distribution of ivermectin in Nigeria.

DESIGN

There was health education with use of pictorial monographs to an adult population and school children in Umulumgbe and Okpatu communities, respectively. The school children in turn transferred the knowledge acquired to their parents through a health club, and a third community (Awhum) had no health education. Randomly selected subjects in each community were then assessed for their ability to recognise clinical manifestations of disease.

SETTING

The study took place in three onchocerciasis-endemic, autonomous communities in Udi local government area of Enugu state in eastern Nigeria.

SUBJECTS

Fifty, thirty seven, and thirty three male subjects, aged 20 years and above in Umulumgbe, Okpatu and Awhum respectively were involved in the study.

RESULTS

89.3%, 100% and 25.6% of the total number of onchocercal nodules were rightly indicated by the subjects in Umulumgbe, Okpatu and Awhum respectively. 100% of skin depigmentation was also reported in Umulumgbe and Okpatu each, and 50% in Awhum. Although some of the clinical manifestations (onchocercal nodules and skin depigmentation) were wrongly indicated, others (hanging groin and enlarged scrotum) were not reported by the subjects at all.

CONCLUSION

This study clearly shows that health education is necessary for control programmes that are meant to be sustainable, especially the WHO-supported community-directed treatment with ivermectin (CDTI).

Willingness to pay for community-based ivermectin distribution: a study of three onchocerciasis-endemic communities in Nigeria

OBJECTIVE

To determine the willingness to pay (WTP) for local ivermectin distribution in a community financing framework.

METHOD

Contingent valuation in three communities in Nigeria, using randomly selected household heads. WTP was elicited using a bidding game, and for collecting information on the households' socio-economic status, level of knowledge, priority ranking and perception of risk of contracting the disease, structured questionnaires were used. Ordinary least squares (OLS) multiple regression analysis was used to analyse factors associated with WTP.

RESULTS

Between 92.1% and 93.3 % of respondents were willing to pay amounts ranging from 5 Naira (US$ 0.06) to 100 Naira (US$ 1.25) (median: 20 Naira, US$ 0.25) in the three communities, more than three times the modelled unit direct cost of distributing ivermectin by the communities themselves. Occupation of the respondent, marital status, average monthly expenditure on health care, manifestations of onchocerciasis, the type of savings scheme embarked on by the respondent, age-group, level of education and type of property were statistically significant (P < 0.05) variables affecting WTP.

CONCLUSION

This study shows that there is WTP for local ivermectin distribution in the three study communities, and that it should be assessed before instituting community-directed treatment with ivermectin.

An improved dosing schedule for ivermectin as a microfilaricidal agent against onchocerciasis

The introduction of ivermectin therapy has proved to be the most important advance in the management and control of onchocerciaisis. By using the standard dosing schedule (150 micrograms/kg) in a mass chemotherapy campaign in Awhum, Nigeria, 128 (14.6%) of 875 eligible subjects used in this study were underdosed while 696 (79.6%) and 51 (5.8%) were overdosed and correctly dosed, respectively. Since underdosing is more serious than overdosing, an improved dosing schedule (300 micrograms/kg) is hereby suggested, bearing in mind that ivermectin is safe at doses well in excess of the standard dose. 824 (94.2%) And 51 (5.8%) of these eligible subjects would be overdosed and correctly dosed respectively, if this improved dosing schedule (< 15 kg, 0 mg (0 tablet); 15-20 kg, 6 mg (1 tablet); 21-40 kg, 12 mg (2 tablets); 41-60 kg, 18 mg (3 tablets); > 60 kg, 24 mg (4 tablets)) were to be employed. This dosing schedule is worth adopting and an investigation of the effects of these high single doses of ivermectin on adult Onchocerca volvolus worms is advocated. Furthermore 'non-responders' may be investigated for doses administered.

An improved technique for the assay of red blood cell superoxide dismutase (SOD) activity

Superoxide dismutase (SOD) activity of erythrocytes from normal pregnant women (controls) and from pre-eclamptic toxaemia (PET) cases was determined by the method of Winterbourn et al. (J Lab Clin Med 1975;85:337-341) with slight modifications. Instead of the Michaelis-Menten type of plot that is usually obtained and which these authors have found to be imprecise, a linear plot was obtained when the reciprocal values for the percentage inhibition of nitroblue tetrazolium (NBT) reduction were plotted against the corresponding volumes of red blood cell (RBC) extract. This plot was found to give precise values for the volumes of RBC extracts required for 50% inhibition of NBT reduction. Consequently, a clearer understanding is beginning to emerge regarding the SOD activity of PET cases compared with that of normal pregnant women.